Provider Demographics
NPI:1700410198
Name:BERGMAN, KEITH
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:BERGMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 HIGHWAY 169 N
Mailing Address - Street 2:
Mailing Address - City:ALGONA
Mailing Address - State:IA
Mailing Address - Zip Code:50511-1019
Mailing Address - Country:US
Mailing Address - Phone:515-295-9238
Mailing Address - Fax:515-295-9214
Practice Address - Street 1:1500 HIGHWAY 169 N
Practice Address - Street 2:
Practice Address - City:ALGONA
Practice Address - State:IA
Practice Address - Zip Code:50511-1019
Practice Address - Country:US
Practice Address - Phone:515-295-9238
Practice Address - Fax:515-295-9214
Is Sole Proprietor?:No
Enumeration Date:2020-02-25
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA18651183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA18651OtherIOWA PHARMACIST LICENSE